Notice to Readers: Shortage of Tetanus and Diphtheria Toxoids

Please note: An
erratum has been published for this article. To view the erratum, please click here.

A temporary shortage of adult tetanus and diphtheria toxoids (Td) in the United
States has resulted from two coincident situations: 1) a decrease in the number of lots
released by Wyeth Lederle (Pearl River, New York), and 2) a temporary decrease in inventory
of vaccine following routine maintenance activities at the production facilities by
Aventis Pasteur (Swiftware, Pennsylvania) that lasted longer than anticipated.
Approximately one half of the usual number of Td doses has been distributed this year. Although
there have been no decreases in production of tetanus toxoid (TT), availability is low
because of increased use during the Td shortage. On the basis of information provided by
Aventis Pasteur, the Public Health Service expects vaccine supplies to be restored early in
2001. Until then, Aventis Pasteur will be limiting orders to assure the widest possible
distribution of available doses.

The shortage will only impact persons aged
>7 years who 1) require tetanus prophylaxis in wound management, 2) have not completed a primary series (three doses)
of vaccine containing Td, or 3) have not been vaccinated during the preceding 10 years
with Td, diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) or diptheria
and tetanus toxoids (DT) (1). This shortage will not affect vaccination of children aged
<7 years who require additional doses of a vaccine-containing TT; they should receive
DTaP or pediatric DT (2), which are not in short supply. Td is preferred to TT because
Td provides protection against both tetanus and diphtheria
(1). However, during this shortage, if Td is not available, TT can be used as an alternative for persons aged
>7 years who require immediate boosting with TT (e.g., wound management), or who are unlikely
to return to a clinic if vaccination is delayed. If TT is administered, patients and
health-care providers must weigh risks and benefits of subsequent vaccination with Td.
Arthus-type reactions may occur among persons who receive multiple doses of TT, especially
within short intervals (<10 years). However, if vaccination with Td is delayed for >10
years following their last Td administration, persons may be protected inadequately
against diphtheria.

Clinics experiencing shortages of Td may need to prioritize their use of
available supplies. If administration of Td is delayed, clinics should implement a call-back
system when vaccine is available. Recommendations for use (highest to lowest priority) of
Td are:

Persons traveling to a country where the risk for diphtheria is high*.

Advisory Committee on Immunization Practices. Pertussis vaccination: use of
acellular pertussis vaccines among infants and young children---recommendations of the
Advisory Committee on Immunization Practices. MMWR 1997;46(no. RR-7).

CDC. Recall of Tripedia Vaccine. MMWR 1999;48:146--7.

* Travelers to certain countries may be at substantial risk for exposure to toxigenic strains
of C. diphtheriae, especially with prolonged travel, extensive contact with children, or
exposure to poor hygiene. On the basis of surveillance data and consultation with the World
Health Organization, countries with highest risk are in Africa (Algeria, Egypt, and
sub-Saharan Africa); the Americas (Brazil, Dominican Republic, Ecuador, and Haiti);
Asia/Oceania (Afghanistan, Bangladesh, Cambodia, China, India, Indonesia, Iran, Iraq, Laos,
Mongolia, Myanmar, Nepal, Pakistan, Philippines, Syria, Thailand, Turkey, Vietnam, and Yemen);
and Europe (Albania and all countries of the former Soviet Union)
(3).

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